The provision of adequate, patient-specific nutrition during hospitalization has been shown to have a significant effect on morbidity and mortality, length of stay (LOS), and costs of care for at-risk and malnourished patients. This is particularly relevant considering that the prevalence of malnutrition in hospitalized patients is approximately 30% to 55%.^1,2 Moreover, once admitted, two-thirds of patients with malnutrition will continue to decline in nutritional status during their inpatient stay if not properly identified and treated with appropriate nutritional interventions.^1-3 However, identification of at-risk or undernourished patients can be challenging due to loss of appetite or gastrointestinal symptoms associated with illness, prolonged nil per os (NPO) status for medical procedures, etc. Combined with the possibility of hyper-metabolic and/or catabolic state(s), these factors can result in at-risk patients becoming malnourished without effective nutritional replenishment. Fortunately, early treatment of nutrient-depleted patients corresponds with improvements in quality and clinical outcomes, as well as reduced costs. 

The use of an interdisciplinary nutrition support team (NST) has been shown to improve patient safety and outcomes and to have a positive financial impact on health care organizations.⁴ Given the increasing expenses associated with hospital stays, and stricter reimbursement policies, the value of a well-rounded, active NST in improving patient safety and reducing costs associated with quality care becomes apparent. Hospitals preparing to implement an NST should start by analyzing the nutritional support needs of the patient population and comparing current practices to clinical guidelines and best-practice standards. 

Building a Multidisciplinary NST 
A multidisciplinary NST should consist of a director, dietitian, nurse, and pharmacist as core members; physicians may use their expertise to assist in an auxiliary capacity. The team’s role is to consult on the management of parenteral nutrition (PN) or enteral nutrition (EN) and to ensure patients safely receive nutrition support by the appropriate route. In addition, determining whether a majority of hospitalized patients utilize EN or PN will be advantageous when assembling an NST team and also when selecting products to stock in the hospital pharmacy. Because PN is more expensive, identifying patient needs will help in calculating the cost-effectiveness of using pre-mixed and/or compounded PN. Other duties may include placing and maintaining nutrition support access devices. Key members of an NST and their roles follow (refer to TABLE 1 for a summary): 

Click here to view a larger version of this Table

Director/Coordinator: As head of the NST, the director is responsible for the overall efficiency and efficacy of the NST in the hospital. The director should help draft, review, and approve all protocols prior to implementation. The director’s overarching goal should be to manage the NST such that it meets or exceeds the facility’s current patient care standards while addressing the needs of the patient population. 

Dietitian(s): Dietitians screen and assess the nutritional status of patients, identify the underlying causes of malnutrition (eg, dysphagia), counsel patients on proper nutrition, and establish dietary guidelines for patients that do not need additional feeding assistance. Dietitians also can assist with the selection of PN or EN for patients, with drafting a transitional feeding plan, and with suggestions for termination of nutritional support.⁵ 

Nurse(s): As nurses are usually involved in overall patient care, they are in an ideal position to make suggestions regarding nutrition. Establishing enteral or intravenous feeding access, performing patient education, and maintaining overall patient care are among nursing’s NST roles.⁶

Pharmacist(s): Because both PN and EN may include complex drug therapies, including a medication expert on the NST is crucial. Pharmacists’ in-depth knowledge of PN compounding processes and product stability and sterility makes them uniquely suited to offer suggestions on ingredient compatibility and hang-times. 

Given the proliferation of drug shortages facing health care providers (eg, potassium phosphate and intravenous multivitamins), recruiting a pharmacist will help the team select alternative options without compromising overall patient care. The multiple drug interactions associated with EN (eg, floroquinolone binding), can be avoided or minimized, and other priority interactions, such as drug/nutrient or drug/drug compatibility, also can be identified and avoided. 

Physician(s): In addition to their diagnosis and prescribing roles, physician champions can provide oversight of the NST and assist with the implementation of NST-established policies and procedures in the hospital. In many facilities, the presence of a physician on the NST aids with reimbursement opportunities, since they are eligible for incident to billing.⁷ A team physician is an asset when managing more complicated patients, such as those suffering multiple traumas. Patients in need of more invasive access (eg, central lines or percutaneous endoscopy gastrostomy tubes) can be assessed and treated in a prompt manner. 

Functions of the NST
The NST can perform multiple functions in overall patient care, including identifying high-risk patients, conducting patient nutritional assessments, calculating protein and calorie goals, addressing free-water requirements, assessing the nutritional route, managing electrolyte replacement and bowel function, and providing ongoing monitoring. 

The prevalence of malnutrition varies by setting and patient population, so it is important to assess your hospital’s capabilities in order to evaluate patient need. As noted earlier, the prevalence of malnutrition in hospitals is 30% to 55%.^1,2 Further exacerbating this problem, two-thirds of these patients become more malnourished during their hospital stay.2 Consequently, identifying high-risk patients is essential. High-risk patients include those with anorexia (from disease-related malnutrition or an eating disorder), heart failure, renal impairment, diabetes, and cancer. All high-risk patients should have a nutrition assessment, regardless of their qualifications for nutritional replacement. Medications, such as antibiotics or chemotherapy, sometimes can contribute to secondary malnutrition, especially when they induce nausea, vomiting, diarrhea, constipation, or loss of appetite. Dysphagia also affects hospitalized patients, especially those with neurological damage such as from a stroke, which can lead to malnutrition. In addition, hospitalized patients often are placed in NPO status for medical procedures; such status can vary from several hours to days.⁴

Once high-risk patients are identified and a total nutritional assessment is complete, the appropriate type of nutritional replacement can be established. An initial assessment will determine nutritional status and identify the optimal nutrition replacement strategy. The importance of an early nutritional assessment is recognized by The Joint Commission, as reflected in its requirement that every patient have a complete nutrition assessment conducted within 24 hours of admission. Determining the type of access required will help with selecting the type of nutrition support; for example, patients without enteral access, or that must remain NPO for extended periods of time, may require intravenous access. For patients requiring enteral access, it is useful to determine what type best suits the needs of the patient (ie, nasogastric tube or small bowel feeding tube). Some patients with enteral access may need more permanent measures, such as PEG tubes or jejunostomy tubes. If a patient loses a source of access, having a member of the NST identify the cause behind the loss can assist in determining a more suitable route. 

Appropriate calculation of patient protein and electrolyte goals will help meet nutrition needs and balance and maintain nitrogen levels. It is important to balance calorie and protein requirements so that patients do not lose lean muscle mass—commonly observed in patients who are bedridden and/or highly catabolic.8 Moreover, patients with certain disease states, such as diabetes, must be carefully assessed; replacement should meet their nutrition goal without exacerbating the disease state. Patients with disease states such as heart failure may have fluid restrictions, thus requiring a more concentrated feeding regimen. Conversely, patients with high fevers, burns, or diarrhea may have free-water loss necessitating replacement. 

Bowel management should be incorporated into the NST’s purview, as assessing the gastrointestinal tract and the input/output of the patient should be part of routine monitoring. This includes patients with losses from ostomy tubes or with high nasogastric output. Patients exhibiting delayed gastric emptying may need to have their nutrition delivery method altered, such as decreasing volumes or switching to small bowel feeding.⁹

Sometimes changing the type of feeding can help with gastrointestinal symptoms of constipation, diarrhea, or even tolerability. For example, switching to peptide-based formulas may help with tolerability and absorption of essential nutrients in critically ill patients with loss of gut integrity. Selecting a product with more fiber may help with bulking of the stools in patients with diarrhea not associated with an infectious process.¹⁰ While the benefit of adding probiotics is controversial, there appears to be a trend toward better outcomes for critically ill patients, and, for most patients, probiotics offer minimal risk.¹¹ Medication recommendations for bowel management also can be made by the NST in order to treat the underlying source of the problem. 

Monitoring parameters must include patient improvements in nutritional status, electrolytes, glucose tolerance, blood gases, hydration status, and bowel function.

• Changes in nutritional status can be assessed via lab tests (eg, pre-albumin), by noting weight changes, and by reviewing trends in nitrogen balance. Keep in mind that caution should be observed when using lab assessments, as pre-albumin levels can be falsely elevated or lowered by disease states and/or medications. Weight changes must not include fluid changes, such as with volume overload or depletion, as hospitalized patients often undergo weight fluctuations due to aggressive fluid replacement, aggressive diuresis, or medical conditions, such as heart failure exacerbations.
• Electrolyte monitoring helps in determining replacement and maintenance levels. 
• Blood glucose must be kept at 180 mg/dL or lower in most patients. Consistently high glucose readings may warrant changes in the nutrition regimen or the addition of insulin therapy. 
• Measuring blood gases can help determine when changes are needed in the replacement regimen by revealing whether the patient is acidotic or in a state of alkalosis. 
• Fluid replacement and maintenance requirements can be assessed by the patient’s hydration status. 
• Tolerability of nutrition replacement can be assessed by monitoring bowel function.

Note that fragmented care leads to complications that can threaten patient safety, as well as burden the hospital with extraneous expenses. Beyond direct patient care in the hospital, another important function of the NST may be to help coordinate transitions in care within the hospital and between heath care systems.

Other auxiliary functions that can be performed by the NST include research, internal audits, patient education, staff education, patient advocacy, and assistance with continuation of home EN and PN. To avoid complications, patients with long-term nutrition needs who receive nutritional support at home must be handled with care when they are transitioned to the hospital formulary (eg, switching between EN formulations or PN compounds).

Gaining Administrative Support for an NST
As increasing hospital funding is dedicated to reducing hospital re-admission rates, addressing the problem—in part, with proper nutrition—presents significant opportunities to avoid loss of reimbursement. Defending the cost-effectiveness of an interdisciplinary NST before hospital board members may be required to gain approval for such a project. In this situation, it is important to elucidate the challenges presented by patients with malnutrition, especially the critically ill. 

When presenting the case for the development of an NST to administration, consider the following: 

• Prevent Infections and Ensure Proper Wound Healing. Patients with malnutrition are more likely to develop infections (eg, pneumonia, urinary tract infections, Clostridium difficile enterocolitis, and skin infections), and poor nutrition can contribute to poor wound healing, thereby indirectly extending the hospital LOS.⁴ 
• Reduce the Incidence of Pressure Ulcers. Pressure ulcers are more commonly exhibited by malnourished elderly patients who do not receive appropriate nutrition intervention.¹² 
• Avert Weight Loss Leading to Readmission. Weight loss after hospital discharge is a strong predictor of readmission within 30 days.^13,14
• Cost Savings. Routine functions of the NST team, such as bowel management, providing access to nutrition and medications, and electrolyte management, also can demonstrate cost savings.

• Bowel management can help prevent chronic constipation or diarrhea, which is associated with significant morbidity 
• Loss of enteral or parenteral access through poor technique may lead to increased costs for replacement parts and additional staff time
• Electrolyte management can help prevent morbidities, such as cardiac and pulmonary complications¹⁵ 
• NSTs that are able to convert patients from PN to EN (ie, those patients for whom it is indicated and tolerated), have been shown to contribute a savings of approximately $1,500 per day from reduced adverse events₁₆ 

Improved Patient Outcomes and Economic Benefits 
Many studies have documented the benefits of proper nutrition replacement with respect to patient outcomes. Moreover, utilizing a robust NST to reduce health care complications often simultaneously reduces significant unreimbursable costs. Consider that the Centers for Medicare and Medicaid Services (CMS) have included pressure ulcers, poor blood sugar control, and falls among preventable hospital-acquired conditions that are not reimbursable.¹⁷ Such costs must be absorbed by the hospital. A cohesive nutrition strategy is an important tool to improve care while controlling these costs.

Malnutrition itself can be expensive, but vigorous identification and treatment of malnourished patients can effectively manage costs. The use of an NST for early identification and treatment of malnutrition can lead to significant reductions in both reimbursable and unreimbursable expenses. One study showed that patients in hospitals with malnutrition who were provided with oral nutrition support had a decrease in hospital costs of up to 21.6% or $4,734.^3,18

Proper nutrition support also may help reduce health care complications, including infections, gastrointestinal perforation, pressure ulcers, and even cardiac-associated issues, in patients with or at-risk for malnutrition. Supporting data highlight the role of specific nutrition interventions in reducing LOS, readmission rates, and possibly mortality, in patients ≥65 years of age with or at-risk for malnutrition.^3,19

Moreover, data indicate that early nutritional intervention may reduce hospital LOS for patients who are severely malnourished by an average of 2.3 to 3.8 days.^5,18,20 The savings associated with reduced LOS is significant. The average cost of a patient’s hospital stay is calculated to be $2,214 per day for non-profit US hospitals,²¹ while the average additional hospital cost for each hospital-acquired infection in the US is $15,275.²² Thus, reducing infection rates may reduce overall LOS, improving patient outcomes and reducing costs. 

Finally, studies have reported a decrease in overall mortality in hospitalized patients with appropriate nutrition intervention, especially among patients with a body mass index less than 20 and elderly patients.¹⁹

Conclusion
The importance of nutritional support during hospitalization is well established. Malnutrition can add to both the financial and clinical burden in hospitals, whereas effective treatment can improve patient and economic outcomes through fewer infections, reduced patient LOS, and decreased costs. Developing an interdisciplinary NST comprising nurses, dietitians, pharmacists, and physicians will help ensure that all patients are adequately fed and assessed for malnutrition. Although launching an NST program may seem daunting at the outset, the initiative can lead to significant long-term benefits for both patients and the organization.

Karrie Derenski, PharmD, BCNSP, CNSC, is the coordinator of the nutrition support service at CoxHealth, Springfield, Missouri. She received her pharmacy degree from the University of Missouri-Kansas City College of Pharmacy and completed a residency in nutrition support at the University of Colorado. Her professional interests include safe and effective use of parenteral and enteral nutrition, diabetes care, and teaching.

Merry Daniel, PharmD, is a PGY1 pharmacy resident at CoxHealth. She received her pharmacy degree from the University of Tennessee College of Pharmacy. Merry’s professional interests include nutrition support, internal medicine, and critical care.

References

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